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BACKGROUND: Recently, fatigue has received more attention as a workplace hazard. This scoping review focuses on fatigue in anaesthesia providers. We explore the prevalence of fatigue in anaesthesia providers, and we examine how fatigue impacts their performance. METHODS: A literature search was independently conducted from December 2019 through March 2020. The following four databases were consulted: MEDLINE, CINAHL, EMBASE, and PubPsych. Only studies discussing fatigue in anaesthesia providers were eligible. RESULTS: The initial database search identified a total of 118 studies, of which 30 studies were included in the review. Eight articles concerned the prevalence of fatigue in anaesthesia providers, whereas 22 explored the impact of fatigue on the performance of anaesthesia providers. Up to 60.8% of anaesthesia providers suffered from severe excessive daytime sleepiness, and fatigue was denoted as a common workplace problem in up to 73.1% of anaesthesia providers. Fatigue had a negative influence on medication errors and vigilance, and it decreased the performance of anaesthesia providers during laboratory psychomotor testing. There was a decrease in non-technical skills (notably communication and teamwork) and worsening mood when fatigued. CONCLUSIONS: Based on this scoping review, fatigue is a prevalent a phenomenon that anaesthesia providers cannot ignore. A combination of deterioration in non technical skills, increased medication errors, loss of sustained attention, and psychomotor decline can lead to poorer performance and cause patient harm. Concrete strategies to mitigate fatigue should be developed.

Offering a global, multidisciplinary perspective on this life-threatening medical emergency, The Sepsis Codex provides a concise yet comprehensive look at a complex topic. Nearly 20% of global deaths are attributed to sepsis annually, nearly half of which are in children under the age of five, with low-resource settings being disproportionately affected. A “one size fits all” approach is not sufficient to meet individual patients’ needs, instead requiring a therapeutic approach that considers different ages, predisposing factors, genetic traits, and more. This cutting-edge resource brings you up to date with recent medical advances in this challenging area.

Purpose of Review The purpose of the present narrative review is to look at the present and future impact of closed-loop technology, artificial intelligence (AI), and machine learning (ML) on anesthesia and patient safety. Recent Findings AI and ML are omnipresent and encountered daily without one’s awareness. More and more promising AI-guided tools are being developed to help anesthesiologists provide better patient care. Some of these applications are already at par or outperforming clinicians in concrete tasks, although significant work is still needed for their effective and safe integration into clinical practice. Additionally, major ethical and legal questions need to be addressed before such algorithms can become mainstream. Summary Despite the challenges ahead, the implementation of AI-driven technologies has significant potential to positively complement modern anesthesia care, and as such, significantly improve patient safety.

Adequate fluid management in sepsis requires a thoughtful approach. While early aggressive fluid therapy is generally required, one should also be aware of the risks of blind continued administration of large fluid volumes. In the first part of this chapter, we offer an in-depth literature overview on the available fluids in sepsis. In the second part, we stress the importance and prove the relevance of viewing fluids as drugs. Finally, we explain that sepsis can be divided into four temporally distinct phases each requiring a different fluid strategy: resuscitation, optimization, stabilization, and evacuation. We offer a phase-by-phase guidance using this ROSE conceptual model.

BackgroundMetabolism of critically ill adult patients is variable and influenced by intrinsic and extrinsic factors. Energy expenditure and thereby metabolism can be captured with indirect calorimetry (IC). An increased respiratory muscle use due to acute hypercapnic failure during Chronic Obstructive Pulmonary Disease exacerbation or other pulmonary problems may increase energy expenditure. Therefore, noninvasive ventilation (NIV) can be used in these conditions. It decreases the work of breathing by supporting muscle activity which will in turn cause a lower muscle metabolism. When this therapy fails, a higher mortality is observed due to delayed intubation. No good single early clinical parameter for NIV failure has been identified. Metabolism seems a promising parameter that has not been researched yet. We explored if IC connected to the NIV device will capture metabolic alterations due to different levels of support with NIV in healthy subjects. Patient and methodsIn this pilot study, metabolism objectified by Resting Energy Expenditure was measured with IC in 5 healthy subjects receiving NIV with increasing levels of support. Noninvasive hemodynamic monitoring was applied. Rate of perceived exertion was also assessed. ResultsDuring increasing levels of inspiratory support, linear regression showed increasing energy expenditure with a function of Y 1 =18,42*X+743,3 and decreasing levels of dyspnea with a function of Y 5 = -0,565*X + 4,42. Friedman test was not significantly different (p=0,364) for energy expenditure but was significantly different (p= 0,014) for the rate of perceived exertion. Further analysis of the rate of perceived exertion with Wilcoxon matched-pairs rank test showed no difference for the different levels of support compared to only positive end-expiratory pressure (PEEP).ConclusionIndirect calorimetry captures metabolic alterations induced by NIV treatment. Metabolism is influenced by increasing levels of support in healthy volunteers. Rate of perceived exertion is not correlated with metabolic alterations induced by NIV.

Introduction COVID-19 infection has resulted in thousands of critically ill patients admitted to ICUs and treated with mechanical ventilation. Percutaneous tracheostomy is a well-known technique utilised as a strategy to wean critically ill patients from mechanical ventilation. Worldwide differences exist in terms of methods, operators, and settings, and questions remain regarding timing and indications. If tracheostomy is to be performed in COVID-19 patients, a safe environment is needed for optimal care. Material and methods We present a guidewire dilating forceps tracheostomy procedure in COVID-19 patients that was optimised including apnoea-moments, protective clothing, checklists, and clear protocols. We performed a retrospective analysis of the outcome after tracheostomy in COVID-19 patients between March 2020 and May 2020. Results The follow-up of the first 16 patients, median age 62 years, revealed a median intubation time until tracheostomy of 18 days and median cannulation time of 20 days. The overall perioperative complication rate and complication rate while cannulated was 19%, mainly superficial bleeding. None of the healthcare providers involved in performing the procedure developed any symptoms of the disease. Conclusions This COVID-19-centred strategy based on flexibility, preparation, and cooperation between healthcare providers with different backgrounds facilitated percutaneous tracheostomy in COVID-19 patients without an increase in the overall complication rate or evidence of risk to healthcare providers. Our findings provide initial evidence that tracheostomy can be performed safely as a standard of care for COVID-19 patients requiring prolonged mechanical ventilation as was standard practice in ICU patients prior to the COVID-19 pandemic to promote ventilator weaning and patient recovery.

BACKGROUND: Better understanding of risk factors for adverse events during monitored anaesthesia care (MAC) for paediatric gastrointestinal endoscopy may improve outcome in children. OBJECTIVES: To identify the prevalence and predictors of adverse events during MAC for paediatric endoscopy. DESIGN: An observational study. SETTING: Tertiary university hospital, single-centre cohort, from January 2010 to August 2016. PATIENTS: The prospectively collected electronic anaesthetic records of 3435 children aged up to 16 years who underwent diagnostic gastrointestinal endoscopy under MAC were analysed retrospectively. Children with an American Society of Anesthesiologists' physical status at least 4, and those requiring mechanical ventilation and therapeutic or urgent endoscopy were excluded. MAIN OUTCOME MEASURES: The prevalence and predictors of adverse events during MAC for paediatric gastrointestinal endoscopy, with particular reference to the use of different anaesthetic or sedative agents. RESULTS: Mean ± SD age of the children was 8.5 ± 4.4 years. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively. Multivariate analysis identified 12 independent predictors: age [odds ratio (OR) 0.92, P = 0.002], children's size for example underweight (OR 1.78, P = 0.039), overweight (OR 2.20, P = 0.039), (morbid) obesity (OR 4.25, P = 0.006), presence of respiratory comorbidities (OR 8.18, P

Most patients undergoing emergency surgery require fluid therapy to correct for fluid losses, restore cardiac output and therefore oxygen delivery. Fluids are drugs and should only be administered when their benefit outweigh the risk of potential side effects. Two principles should be kept in mind when administering IV fluids: the 4 D’s of fluid therapy (Drug, Dose, Duration and De-escalation) and the ROSE principle (Resuscitation, Optimization, Stabilization, Evacuation). Crystalloids, colloids and blood products have different characteristics that should be taken into account when selecting the “right fluid for the job” to restore intravascular volume depletion. The decision on whether or not to start, continue, or stop fluid administration should be based on a thorough clinical exam and a multitude of hemodynamic parameters. Advanced hemodynamic monitoring devices can support decision-making. Patients receiving fluids should be frequently reassessed to determine whether fluid administration can be halted and detect adverse events related to fluid under- or overloading.